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Vandenplas Y, Broekaert I, Domellöf M, Indrio F, Lapillonne A, Pienar C, Ribes-Koninckx C, Shamir R, Szajewska H, Thapar N, Thomassen RA, Verduci E, West C. An ESPGHAN Position Paper on the Diagnosis, Management, and Prevention of Cow's Milk Allergy. J Pediatr Gastroenterol Nutr 2024; 78:386-413. [PMID: 38374567 DOI: 10.1097/mpg.0000000000003897] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 06/25/2023] [Indexed: 07/27/2023]
Abstract
A previous guideline on cow's milk allergy (CMA) developed by the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) was published in 2012. This position paper provides an update on the diagnosis, treatment, and prevention of CMA with focus on gastrointestinal manifestations. All systematic reviews and meta-analyses regarding prevalence, pathophysiology, symptoms, and diagnosis of CMA published after the previous ESPGHAN document were considered. Medline was searched from inception until May 2022 for topics that were not covered in the previous document. After reaching consensus on the manuscript, statements were formulated and voted on each of them with a score between 0 and 9. A score of ≥6 was arbitrarily considered as agreement. Available evidence on the role of dietary practice in the prevention, diagnosis, and management of CMA was updated and recommendations formulated. CMA in exclusively breastfed infants exists, but is uncommon and suffers from over-diagnosis. CMA is also over-diagnosed in formula and mixed fed infants. Changes in stool characteristics, feeding aversion, or occasional spots of blood in stool are common and in general should not be considered as diagnostic of CMA, irrespective of preceding consumption of cow's milk. Over-diagnosis of CMA occurs much more frequently than under-diagnosis; both have potentially harmful consequences. Therefore, the necessity of a challenge test after a short diagnostic elimination diet of 2-4 weeks is recommended as the cornerstone of the diagnosis. This position paper contains sections on nutrition, growth, cost, and quality of life.
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Affiliation(s)
- Yvan Vandenplas
- Vrije Universiteit Brussel (VUB), UZ Brussel, KidZ Health Castle, Brussels, Belgium
| | - Ilse Broekaert
- Department of Paediatrics, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Magnus Domellöf
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
| | - Flavia Indrio
- Department of Medical and Surgical Science, University of Foggia, Foggia, Italy
| | - Alexandre Lapillonne
- Neonatal Intensive Care Unit, Necker-Enfants Malades Hospital, Paris University, Paris, France
- CNRC, Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Corina Pienar
- Department of Pediatrics, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Carmen Ribes-Koninckx
- Gastroenterology and Hepatology & Instituto de Investigacion Sanitaria, La Fe University Hospital, Valencia, Spain
| | - Raanan Shamir
- Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children's Medical Center, Lea and Arieh Pickel Chair for Pediatric Research, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Hania Szajewska
- Department of Paediatrics, The Medical University of Warsaw, Warsaw, Poland
| | - Nikhil Thapar
- Gastroenterology, Hepatology and Liver Transplant, Queensland Children's Hospital, Brisbane, Australia
- School of Medicine, University of Queensland, Brisbane, Australia
- Woolworths Centre for Child Nutrition Research, Queensland University of Technology, Brisbane, Australia
- UCL Great Ormond Street Institute of Child Health, London, UK
| | - Rut Anne Thomassen
- Department of Paediatric Medicine, Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Elvira Verduci
- Department of Paediatrics, Vittore Buzzi Children's Hospital, University of Milan, Milan, Italy
| | - Christina West
- Department of Clinical Sciences, Pediatrics, Umeå University, Umeå, Sweden
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Hubbard GP, Atwal K, Graham L, Narayanan S, Cooke L, Casewell C, Denton SA, Gavin J, Browne RM, Kinnear FJ, McHardy AJ, Evans D, Vallis R, Venkataraman D, Cawood AL, Donohoe S, Steele V, Armstrong S, Stratton RJ. Synbiotic containing extensively hydrolyzed formula improves gastrointestinal and atopic symptom severity, growth, caregiver quality of life, and hospital-related healthcare use in infants with cow's milk allergy. Immun Inflamm Dis 2022; 10:e636. [PMID: 35634950 PMCID: PMC9119008 DOI: 10.1002/iid3.636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 04/28/2022] [Accepted: 05/01/2022] [Indexed: 12/13/2022] Open
Abstract
Background Healthy gut microbiota is important for prognosis in cow's milk allergy (CMA). The application of synbiotics (specific pre‐ and probiotics) in extensively hydrolyzed formulae (eHFs) is a relatively new concept. Aims To evaluate a synbiotic‐containing, whey‐based eHF (SeHF) with galacto‐oligosaccharides, fructo‐oligosaccharides, and bifidobacterium breve M‐16V in infants with CMA. Materials and Methods A 31‐day one‐arm pilot study in 29 infants with CMA (mean age 30.8 weeks [SD 11]) was undertaken, with outcomes including gastrointestinal tolerance, atopic dermatitis symptoms, dietary intake, growth, SeHF acceptability, caregiver quality of life, and hospital‐related healthcare use. Results Significant improvements (p < .05) in the severity of abdominal pain (in 57%), burping (in 46%), flatulence (in 79%), constipation (in 14%), rhinitis (41%), and itchy eyes (73%), as well as atopic dermatitis in those with severe baseline symptoms (PO‐SCORAD© reduction: 34.7–18.2 (p = .003), n = 6) were observed over time. Growth and caregiver quality of life scores significantly increased (+26.7%, p < .05) over time. Hospital visits and medications significantly reduced (−1.61 and −2.23, respectively, p < .005) in the 6 months after SeHF initiation. Discussion In this small, single‐arm, pilot study, the use of SeHF enhanced the management of infants with non‐IgE mediated CMA who were already established on eHF. Conclusion: Whilst this study adds to the evidence base for the use of SeHF in CMA, further robust research to explore the longer‐term benefits of synbiotics, specifically the blend used in this study, for the clinical management of infants with CMA is warranted.
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Affiliation(s)
| | | | - Lynne Graham
- West Hertfordshire Hospitals NHS Trust, Watford, UK
| | | | - Lisa Cooke
- Bristol Royal Hospital for Children, Bristol, UK
| | | | - Sally-Ann Denton
- University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - Joan Gavin
- University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | | | | | - Ailsa J McHardy
- University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - Debbie Evans
- Royal Surrey NHS Foundation Trust, Guildford, UK
| | | | | | | | - Sarah Donohoe
- James Cook Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Victoria Steele
- James Cook Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Sonia Armstrong
- James Cook Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Rebecca J Stratton
- Nutricia Ltd, Trowbridge, UK.,Faculty of Medicine, University of Southampton, Southampton, UK
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Fong AT, Ahlstedt S, Golding MA, Protudjer JLP. The Economic Burden of Food Allergy: What We Know and What We Need to Learn. CURRENT TREATMENT OPTIONS IN ALLERGY 2022; 9:169-186. [PMID: 35502316 PMCID: PMC9046535 DOI: 10.1007/s40521-022-00306-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2022] [Indexed: 02/04/2023]
Abstract
Purpose of Review Food allergy management and treatment require dietary modification, are associated with significant burdens, and affect food choices and behaviours. Emerging therapies, such as oral immunotherapy (OIT), provide a glimmer of hope for those living with the condition. Some burdens have received substantial focus, whereas many knowledge gaps on the significance of other impacts, including economic burden, remain. Recent Findings Evidence from many countries, but disproportionately from the United States, supports that food allergy carries significant healthcare and societal costs. Early introduction for the prevention of food allergies is theoretically cost-effective, but remains largely undescribed. Unique considerations, such as those to cow’s milk protein allergy, which affects a substantial proportion of infants, and adrenaline autoinjectors, which have a high cost-per-use, require a balance between cost-effectiveness to the healthcare system and adverse outcomes. Household costs have largely been explored in two countries, but owing to different healthcare structures and costs of living, comparisons are difficult, as are generalisations to other countries. Stock epinephrine in schools may present a cost-effective strategy, particularly in economically disadvantaged areas. Costs relating to OIT must be examined within both immediate benefits, such as protection from anaphylaxis, and long-term benefits, such as sustained unresponsiveness. Summary Although the absolute costs differ by region/country and type of food allergy, a consistent pattern persists: food allergy is a costly condition, to those who live with it, and the multiple stakeholders with which they interact. Supplementary Information The online version contains supplementary material available at 10.1007/s40521-022-00306-5.
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Affiliation(s)
| | - Staffan Ahlstedt
- Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden
| | - Michael A. Golding
- The Children’s Hospital Research Institute of Manitoba, 501G-715 McDermot Avenue, Winnipeg, MB R3E 3P4 Canada
- Department of Pediatrics and Child Health, The University of Manitoba, 501G-715 McDermot Avenue, Winnipeg, MB R3E 3P4 Canada
| | - Jennifer L. P. Protudjer
- Centre for Allergy Research, Karolinska Institutet, Stockholm, Sweden
- The Children’s Hospital Research Institute of Manitoba, 501G-715 McDermot Avenue, Winnipeg, MB R3E 3P4 Canada
- Department of Pediatrics and Child Health, The University of Manitoba, 501G-715 McDermot Avenue, Winnipeg, MB R3E 3P4 Canada
- George and Fay Yee Centre for Healthcare Innovation, 501G-715 McDermot Avenue, Winnipeg, MB R3E 3P4 Canada
- Food and Human Nutritional Sciences, The University of Manitoba, 501G-715 McDermot Avenue, Winnipeg, MB R3E 3P4 Canada
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4
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Fanning L, Woods E, Hornung CJ, Perrett KP, Tang MLK, Dalziel K. Cost-Effectiveness of Food Allergy Interventions in Children: A Systematic Review of Economic Evaluations. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:1360-1376. [PMID: 34452717 DOI: 10.1016/j.jval.2021.02.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 02/10/2021] [Accepted: 02/18/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES To identify published economic evaluations of interventions aimed at preventing, diagnosing, or treating food allergies in children. METHODS We examined economic evaluations published from 2000 to 2019. Data analyzed included: food allergy type, study population/setting, intervention/comparator, and economic evaluation details. Quality assessment used reporting and economic modeling checklists. Two reviewers simultaneously undertook article screening, data extraction, and quality assessment. RESULTS 17 studies were included: 8 peanut allergy (PA) studies, 8 cow's milk allergy (CMA) studies, and 1 egg allergy (EA) study. All PA studies reported incremental costs per quality-adjusted life-year gained for diagnostic strategies, management pathways for peanut exposure, and immunotherapies. Immunotherapies rendered inconsistent cost-effectiveness results. CMA studies reported costs per symptom-free day or probability of developing CMA tolerance. Cost-effectiveness of extensively hydrolyzed casein formula for CMA treatment was consistently demonstrated. Early introduction of cooked egg in first year of life dominated all EA prevention strategies. Quality assessment showed average noncompliance for 3.5 items/study (range 0-11) for modeling methods and 3.4 items/study (range 0-8) for reporting quality. Key quality concerns included limited justification for model choice, evidence base for model parameters, source of utility values, and representation of uncertainty. CONCLUSION Recent cost-effectiveness literature of interventions in PA, CMA, and EA is limited and diverse. Interventions for diagnosis and treatment of CMA and prevention of EA were generally cost-effective; however, results for PA were variable and dependent on effectiveness and utility values used. There is a need to expand economic evaluation of interventions for childhood food allergy and to improve methods and reporting.
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Affiliation(s)
- Laura Fanning
- Health Economics Group, Centre for Health Policy, Melbourne School of Global and Population Health, University of Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Centre for Health Economics, Monash Business School, Monash University, Victoria, Australia
| | - Ekaterina Woods
- Health Economics Group, Centre for Health Policy, Melbourne School of Global and Population Health, University of Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | | | - Kirsten P Perrett
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia; Department of Allergy and Immunology, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Mimi L K Tang
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia; Department of Allergy and Immunology, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Kim Dalziel
- Health Economics Group, Centre for Health Policy, Melbourne School of Global and Population Health, University of Melbourne, Victoria, Australia; Murdoch Children's Research Institute, Melbourne, Victoria, Australia.
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The Use of an Amino Acid Formula Containing Synbiotics in Infants with Cow's Milk Protein Allergy-Effect on Clinical Outcomes. Nutrients 2021; 13:nu13072205. [PMID: 34199007 PMCID: PMC8308253 DOI: 10.3390/nu13072205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/11/2021] [Accepted: 06/25/2021] [Indexed: 11/25/2022] Open
Abstract
Cow’s milk protein allergy (CMPA) is common and costly. Clinical trials of infants with CMPA have shown that the use of an amino acid formula containing pre- and probiotics (synbiotics) (AAF-Syn) may lead to significant reductions in infections, medication prescriptions and hospital admissions, compared to AAF without synbiotics. These effects have not yet been confirmed in real-world practice. This retrospective matched cohort study examined clinical and healthcare data from The Health Improvement Network database, from 148 infants with CMPA (54% male, mean age at diagnosis 4.69 months), prescribed either AAF-Syn (probiotic Bifidobacterium breve M16-V and prebiotics, including chicory-derived oligo-fructose and long-chain inulin) or AAF. AAF-Syn was associated with fewer symptoms (−37%, p < 0.001), infections (−35%, p < 0.001), medication prescriptions (−19%, p < 0.001) and healthcare contacts (−18%, p = 0.15) vs. AAF. Infants prescribed AAF-Syn had a significantly higher probability of achieving asymptomatic management without hypoallergenic formula (HAF) (adjusted HR 3.70, 95% CI 1.97–6.95, p < 0.001), with a shorter clinical course of symptoms (median time to asymptomatic management without HAF 1.35 years vs. 1.95 years). AAF-Syn was associated with potential cost-savings of £452.18 per infant over the clinical course of symptoms. These findings may be attributable to the effect of the specific synbiotic on the gut microbiome. Further research is warranted to explore this. This real-world study provides evidence consistent with clinical trials that AAF-Syn may produce clinical and healthcare benefits with potential economic impact.
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Sekkidou M, Muhardi L, Constantinou C, Kudla U, Vandenplas Y, Nicolaou N. Nutritional Management With a Casein-Based Extensively Hydrolysed Formula in Infants With Clinical Manifestations of Non-IgE-Mediated CMPA Enteropathies and Constipation. FRONTIERS IN ALLERGY 2021; 2:676075. [PMID: 35387002 PMCID: PMC8974831 DOI: 10.3389/falgy.2021.676075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/03/2021] [Indexed: 12/02/2022] Open
Abstract
Background: The majority of mixed-fed infants with non-IgE-mediated cow's milk protein allergy (CMPA) enteropathies are managed with an extensively hydrolysed cow's milk based infant formula (eHF). Given the high variability in peptide distribution of available eHFs, it is important to understand the suitability of a specific product in the management of distinct phenotypes. Objective: To assess the symptom resolution of various phenotypes of clinical manifestations of CMPA enteropathies and constipation managed by a casein-based eHF. Methods: The data of 20 full-term infants (n = 15 with non-IgE-mediated CMPA and n = 5 with constipation) attending a paediatric allergy clinic in Cyprus and managed with a casein-based eHF were retrospectively analysed. Results: Based on the clinical symptoms and history, infants were classified into the following phenotypes: (a) 11/15 (73.3%) FPIAP, (b) 3/15 (20%) FPIES, and (c) 1/15 (6.7%) severe diarrhoea. Overall, 14 (93.3%) patients were successfully managed with the casein-based eHF and 1 (6.7%) required an AAF. This formula was effective in 91% of patients with FPIAP, in 100% with FPIES and with diarrhoea. Three (60%) patients with constipation responded to the eHF. Conclusion: This case-series report supports the efficacy of a particular casein-based eHF for the nutritional management of non-IgE mediated CMPA enteropathies.
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Affiliation(s)
| | - Leilani Muhardi
- Friesland Campina AMEA, Singapore, Singapore
- *Correspondence: Leilani Muhardi
| | | | | | - Yvan Vandenplas
- Kidz Health Castle University Hospital Brussels, Brussels, Belgium
| | - Nicolaos Nicolaou
- N Asthma and Allergy Center, Limassol, Cyprus
- University of Nicosia Medical School, Nicosia, Cyprus
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Zepeda-Ortega B, Goh A, Xepapadaki P, Sprikkelman A, Nicolaou N, Hernandez REH, Latiff AHA, Yat MT, Diab M, Hussaini BA, Setiabudiawan B, Kudla U, van Neerven RJJ, Muhardi L, Warner JO. Strategies and Future Opportunities for the Prevention, Diagnosis, and Management of Cow Milk Allergy. Front Immunol 2021; 12:608372. [PMID: 34177882 PMCID: PMC8222906 DOI: 10.3389/fimmu.2021.608372] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 05/04/2021] [Indexed: 12/31/2022] Open
Abstract
The prevalence of food allergy has increased over the last 20-30 years, including cow milk allergy (CMA) which is one of the most common causes of infant food allergy. International allergy experts met in 2019 to discuss broad topics in allergy prevention and management of CMA including current challenges and future opportunities. The highlights of the meeting combined with recently published developments are presented here. Primary prevention of CMA should start from pre-pregnancy with a focus on a healthy lifestyle and food diversity to ensure adequate transfer of inhibitory IgG- allergen immune complexes across the placenta especially in mothers with a history of allergic diseases and planned c-section delivery. For non-breastfed infants, there is controversy about the preventive role of partially hydrolyzed formulae (pHF) despite some evidence of health economic benefits among those with a family history of allergy. Clinical management of CMA consists of secondary prevention with a focus on the development of early oral tolerance. The use of extensive Hydrolysate Formulae (eHF) is the nutrition of choice for the majority of non-breastfed infants with CMA; potentially with pre-, probiotics and LCPUFA to support early oral tolerance induction. Future opportunities are, among others, pre- and probiotics supplementation for mothers and high-risk infants for the primary prevention of CMA. A controlled prospective study implementing a step-down milk formulae ladder with various degrees of hydrolysate is proposed for food challenges and early development of oral tolerance. This provides a more precise gradation of milk protein exposure than those currently recommended.
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Affiliation(s)
- Benjamin Zepeda-Ortega
- Pediatric Allergist Private Practice, Angeles Lomas Hospital Huixquilucan Mexican State, Mexico City, Mexico
| | - Anne Goh
- Department of Paediatrics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Paraskevi Xepapadaki
- Allergy Department, 2nd Pediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
| | - Aline Sprikkelman
- Department of Pediatric Pulmonology and Pediatric Allergology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | | | | | | | - Miu Ting Yat
- Department of Paediatrics, Queen Elizabeth Hospital, Hong Kong, China
| | - Mohamed Diab
- Pediatric Department Faculty of Medicine, Children Hospital Cairo University, Cairo, Egypt
| | - Bakr Al Hussaini
- Department of Pediatrics, Abdul Aziz University Hospital, Jeddah, Saudi Arabia
| | - Budi Setiabudiawan
- Department of Child Health, Faculty of Medicine, Univesitas Padjadjaran, Bandung, Indonesia.,Department of Pediatrics, Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
| | | | - R J Joost van Neerven
- R&D, FrieslandCampina, Amersfoort, Netherlands.,Wageningen University & Research, Wageningen, Netherlands
| | - Leilani Muhardi
- Medical Affairs, Friesland Campina AMEA, Singapore, Singapore
| | - John O Warner
- Inflammation Repair and Development, National Heart and Lung Institute Imperial College, London, United Kingdom.,Paediatrics, University of Cape Town, Cape Town, South Africa
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Using Eosinophil Biomarkers From Rectal Epithelial Samples to Diagnose Food Protein-induced Proctocolitis: A Pilot Study. J Pediatr Gastroenterol Nutr 2020; 71:e109-e112. [PMID: 32960539 DOI: 10.1097/mpg.0000000000002812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES The gold standard diagnostic procedure for food protein-induced proctocolitis (FPIP) requires flexible sigmoidoscopy (FS). To date there is no validated, noninvasive test to confirm FPIP diagnosis. Eosinophil-derived neurotoxin (EDN), a product of eosinophil (EOS) degranulation, has been shown to correlate with eosinophil infiltration in other tissues. Our objective was to compare EDN concentrations in rectal epithelial samples from infants with FPIP with those from a control population. METHODS Children who underwent routine FS at Arnold Palmer Hospital for Children were enrolled in an IRB-approved, prospective, open-label pilot study between July 2017 and May 2019. We obtained rectal epithelial samples via: rectal swab, cytology brushing through FS, and rectal biopsy through FS. We then measured EDN levels in the samples and compared levels found in infants with FPIP against levels found in the control group. FPIP was defined as more than 60 EOS per 10 high-power fields (HPF) in rectal epithelial tissue obtained via rectosigmoid biopsy. RESULTS Twenty-four patients were enrolled. The control group (n = 13) included patients with normal histopathology (84% boys, mean age 19 months, SD 6 months) and the FPIP group (n = 11) included patients with FPIP confirmed via biopsy (45% boys, mean age 6.9 months, SD 9 months). EDN concentration was significantly higher in the FPIP group than in the control group, for 2 sampling methods: rectal biopsy (183.6 ± 114.6 vs 76.6 ± 71.0 μg/mL; P = 0.010) and rectal swab (66.2 ± 64.8 vs 20.4 ± 22.2 μg/mL; P = 0.025). CONCLUSIONS EDN concentrations measured from rectal swab and rectal biopsy samples is elevated and may be a useful tool to screen for FPIP in children.
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9
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Berktas M, Kirbiyik F, Aribal E, Aksit A, Altintas DU. Treatment Options for Cow's Milk Protein Allergy: A Modeling Analysis. CLINICOECONOMICS AND OUTCOMES RESEARCH 2020; 12:307-315. [PMID: 32606847 PMCID: PMC7306455 DOI: 10.2147/ceor.s242021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 03/18/2020] [Indexed: 11/23/2022] Open
Abstract
Purpose Cow's milk protein allergy (CMPA) is one of the most common food allergies in early childhood. We aimed to evaluate clinical and economic outcomes of the amino-acid formula (AAF) and extensively hydrolyzed formula (eHF) based treatment of CMPA by using data available from Turkey and otherwise from literature. Materials and Methods A theoretical model was developed to evaluate AAF and eHF for CMPA treatment in terms of the number of children tolerating formula or experiencing an allergic reaction or withdrawing formula due to taste or other palatability features and CMPA related direct medical costs from the payer perspective. Results We estimated that 13,000 children are diagnosed with CMPA in 1 year in Turkey. For the children receiving AAF, it is estimated that 83.7% tolerate AAF until the 24th month, and the total cost for the children tolerating AAF is estimated at 20.6 million€. The average cost per child tolerating AAF until the 24th month is estimated at 1895€. On the other hand, 48.7% are estimated to tolerate eHF until the 24th month, and the total cost for the children tolerating eHF is estimated at 12.3 million€ and the average cost per child tolerating eHF until the 24th month is estimated at 1940€. Conclusion The analysis revealed that the management of CMPA is associated with the economic burden on the healthcare system in Turkey. Treatment of CMPA with AAF seems to provide better clinical outcomes (high tolerability and less withdrawal due to taste or an allergic reaction) and to be an option with economic benefits when Turkey-specific conditions are considered.
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Affiliation(s)
| | - Feza Kirbiyik
- Nutricia Advanced Medical Nutrition, Istanbul, Turkey
| | - Elif Aribal
- Nutricia Advanced Medical Nutrition, Istanbul, Turkey
| | - Anil Aksit
- Nutricia Advanced Medical Nutrition, Istanbul, Turkey
| | - Derya Ufuk Altintas
- Cukurova University Medical School, Allergy and Immunology Department, Adana, Turkey
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10
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Maslin K, Fox AT, Chambault M, Meyer R. Palatability of hypoallergenic formulas for cow's milk allergy and healthcare professional recommendation. Pediatr Allergy Immunol 2018; 29:857-862. [PMID: 30192414 DOI: 10.1111/pai.12979] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 07/31/2018] [Accepted: 08/09/2018] [Indexed: 01/28/2023]
Abstract
BACKGROUND Cows 'milk protein allergy (CMPA) is the most common food allergy in infants in the United Kingdom. Infants with CMPA who are not exclusively breastfed require a substitute hypoallergenic formula, which are perceived as having a poor palatability. This study compares the palatability of different extensively hydrolysed formulas (EHFs) and explores healthcare professional (HCP) expectations of how palatability impacts infants and their families. METHODS Healthcare professional with experience of CMPA were recruited to take part in a home palatability test of four EHFs [Aptamil Pepti 1, Nutricia Ltd. (EHF W1); Althera, Nestle Health Science (EHF W2); Similac Alimentum, Abbott (EHF C1); Nutramigen LGG 1, Mead Johnson (EHF C2)] using a blind taste procedure. A randomised, complete block design was used to minimise order and carry-over biases. Participants completed a questionnaire about the impact of formula palatability on infants and their families. RESULTS A total of 100 HCPs took part (51 dietitians and 49 general practitioners). Overall, whey-based lactose-containing EHFs were ranked the most palatable: EHF W1 by 77% of participants and EHF W2 by 20%. EHF W1 was liked significantly more (P < 0.0001) than the other formulas. The vast majority of participants agreed that better palatability would result in an increased chance of non-rejection (96%), more content families (92%) and decreased healthcare costs (90%). CONCLUSION Amongst HCPs who manage infants with CMPA, whey-based lactose-containing EHFs were ranked the most palatable. HCPs expected that good palatability would result in better acceptance, more content infants and families, alongside decreased wastage and healthcare costs.
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Affiliation(s)
- Kate Maslin
- School of Health Sciences and Social Work, University of Portsmouth, Portsmouth, UK
| | - Adam T Fox
- Department of Paediatric Allergy, Guy's& St Thomas' Hospitals NHS Foundation Trust, London, UK
| | | | - Rosan Meyer
- Department of Paediatrics, Imperial College, London, UK
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Uday S, Sakka S, Davies JH, Randell T, Arya V, Brain C, Tighe M, Allgrove J, Arundel P, Pryce R, Högler W, Shaw NJ. Elemental formula associated hypophosphataemic rickets. Clin Nutr 2018; 38:2246-2250. [PMID: 30314926 DOI: 10.1016/j.clnu.2018.09.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 07/24/2018] [Accepted: 09/21/2018] [Indexed: 01/28/2023]
Abstract
OBJECTIVES Hypophosphataemic rickets (HR) is usually secondary to renal phosphate wasting but may occur secondary to reduced intake or absorption of phosphate. We describe a series of cases of HR associated with the use of Neocate®, an amino-acid based formula (AAF). METHODS A retrospective review of cases with HR associated with AAF use presenting to centres across the United Kingdom. RESULTS 10 cases were identified, over a 9 month period, all associated with Neocate® use. The age at presentation was 5 months to 3 years. The majority (8/10) were born prematurely. Gastro oesophageal reflux disease (6/10) was the most frequent indication for AAF use. Radiologically apparent rickets was observed after a median of 8 months (range 3-15 months) of exclusive Neocate® feed. The majority (7/10) were diagnosed on the basis of incidental findings on radiographs: rickets (6/10) or fracture with osteopenia (5/10). All patients had typical biochemical features of HR with low serum phosphate, high alkaline phosphatase, normal serum calcium and 25 hydroxyvitamin D. However, in all cases the tubular reabsorption of phosphate (TRP) was ≥96%. Phosphate supplementation resulted in normalisation of serum phosphate within 1-16 weeks, and levels remained normal only after Neocate® cessation. In patients with sufficient follow up duration (4/10), normalisation of phosphate and radiological healing of rickets was noted after 6 months (range: 6-8 months) following discontinuation of Neocate®. CONCLUSION The presence of a normal TRP and resolution of hypophosphataemia and rickets following discontinuation of Neocate® indicates this is a reversible cause likely mediated by poor phosphate absorption. Close biochemical surveillance is recommended for children on Neocate®, especially in those with gastrointestinal co-morbidities, with consideration of a change in feed or phosphate supplementation in affected children.
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Affiliation(s)
- S Uday
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Birmingham, UK; Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - S Sakka
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Birmingham, UK
| | - J H Davies
- Department of Endocrinology and Diabetes, University Hospital Southampton, Southampton, UK
| | - T Randell
- Department of Paediatric Endocrinology and Diabetes, Nottingham Children's Hospital, Nottingham, UK
| | - V Arya
- Department of Paediatric Endocrinology, Great Ormond Street Hospital, London, UK
| | - C Brain
- Department of Paediatric Endocrinology, Great Ormond Street Hospital, London, UK
| | - M Tighe
- Poole Hospital NHS Foundation Trust, Poole, UK
| | - J Allgrove
- Department of Paediatric Endocrinology, Great Ormond Street Hospital, London, UK
| | - P Arundel
- Department of Metabolic Bone Disease, Sheffield Children's Hospital, Sheffield, UK
| | - R Pryce
- Department of Paediatrics, Royal Gwent Hospital, Newport, UK
| | - W Högler
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Birmingham, UK; Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - N J Shaw
- Department of Endocrinology and Diabetes, Birmingham Children's Hospital, Birmingham, UK; Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK.
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Guest JF, Kobayashi RH, Mehta V, Neidich G. Cost-effectiveness of using an extensively hydrolyzed casein formula containing Lactobacillus rhamnosus GG in managing infants with cow's milk allergy in the US. Curr Med Res Opin 2018; 34:1539-1548. [PMID: 29098889 DOI: 10.1080/03007995.2017.1400962] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To estimate the cost-effectiveness of using an extensively hydrolyzed casein formula containing the probiotic Lactobacillus rhamnosus GG (eHCF + LGG; Nutramigen LGG) compared with an eHCF alone and an amino acid formula (AAF) in treating cow's milk allergy (CMA) in the US, from the perspective of third-party insurers and from parents. METHODS A decision model was used to estimate the probability of cow's milk allergic infants developing tolerance to cow's milk by 18 months. The model also estimated the cost to insurers and parents (US dollars at 2016 prices) of managing infants over 18 months after starting one of the formulae, as well as the relative cost-effectiveness of each of the formulae. RESULTS The probability of developing tolerance to cow's milk was higher among infants who were fed eHCF + LGG compared with those fed an eHCF alone or an AAF. Infants who are initially fed with eHCF + LGG are expected to utilize fewer healthcare resources than those fed with one of the other formulae. Hence, the estimated total healthcare cost incurred by third-party insurers and parents of initially feeding infants with eHCF + LGG was less than that of feeding infants with an eHCF alone or an AAF. CONCLUSION Initial management of newly-diagnosed cow's milk allergic infants with eHCF + LGG was found to afford a cost-effective strategy to both third-party insurers and parents when compared to an eHCF alone or an AAF.
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Affiliation(s)
- Julian F Guest
- a Catalyst Health Economics Consultants , Rickmansworth, Hertfordshire , UK
- b Faculty of Life Sciences and Medicine , King's College , London , UK
| | | | - Vinay Mehta
- d Allergy, Asthma & Immunology Associates , PC , Lincoln , NE , US
| | - Gary Neidich
- e Sanford Children's Clinic and Sanford School of Medicine of the University of South Dakota , Sioux Falls , SD , USA
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Sekerel BE, Seyhun O. Expert panel on practice patterns in the management of cow's milk protein allergy and associated economic burden of disease on health service in Turkey. J Med Econ 2017; 20:923-930. [PMID: 28602101 DOI: 10.1080/13696998.2017.1342171] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIMS To evaluate practice patterns in the management of cow's milk protein allergy (CMPA) and associated economic burden of disease on health service in Turkey. MATERIALS AND METHODS This study was based on experts' views on the practice patterns in management of CMPA manifesting with either proctocolitis or eczema symptoms and, thereby, aimed to estimate economic burden of CMPA. Practice patterns were determined via patient flow charts developed by experts using the modified Delphi method for CMPA presented with proctocolitis and eczema. Per patient total 2-year direct medical costs were calculated, including cost items of physician visits, laboratory tests, and treatment. RESULTS According to the consensus opinion of experts, 2-year total direct medical cost from a payer perspective and societal perspective was calculated to be $US2,116.05 and $US2,435.84, respectively, in an infant with CMPA presenting with proctocolitis symptoms, and $US4,001.65 and $US4,828.90, respectively, in an infant with CMPA presenting with eczema symptoms. Clinical nutrition was the primary cost driver that accounted for 89-92% of 2-year total direct medical costs, while the highest total direct medical cost estimated from a payer perspective and societal perspective was noted for the management of an exclusively formula-fed infant presenting either with proctocolitis ($US3,743.85 and $US4,025.63, respectively) or eczema ($US6,854.10 and $US7,917.30, respectively). The first line use of amino acid based formula (AAF) was associated with total direct cost increment $US1,848.08 and $US3,444.52 in the case of proctocolitis and eczema, respectively. LIMITATIONS Certain limitations to this study should be considered. First, being focused only on direct costs, the lack of data on indirect costs or intangible costs of illness seems to be a major limitation of the present study, which likely results in a downward bias in the estimates of the economic cost of CMPA. Second, given the limited number of studies concerning epidemiology and practice patterns in CMPA in Turkey, use of expert clinical opinion of the panel members rather than real-life data on practice patterns that were used to identify direct medical costs might raise a concern with the validity and reliability of the data. Also, while this was a three-step study with six experts included in the first stage (developing local guidelines for diagnosis, treatment, and follow-up of infants with CMPA in Turkey) and 410 pediatricians included in the second stage (a cross-sectional questionnaire-survey to determine pediatricians' awareness and practice of CMPA in infants and children), only four members were included in the present Delphi panel, which allows a limited discussion. Third, lack of sensitivity analyses and exclusion of indirect costs and costs related to alterations in quality of life, behavior of infants, and general well-being of infants and their parents from the cost-analysis seems to be another limitation that may have caused under-estimation of relative cost-effectiveness of the formulae. Fourth, calculation of costs per local guidelines rather than real-life practice patterns is another limitation that, otherwise, would extend the knowledge achieved in the current study. Notwithstanding these limitations, the present expert panel provided practice patterns in the management of CMPA and an estimate of the associated costs, depending on the symptom profile at initial admission for the first time in Turkey. CONCLUSIONS In conclusion, in providing the first health economic data on CMPA in Turkey, the findings revealed that CMPA imposes a substantial burden on the Turkish healthcare system from both a payer perspective and societal perspective, and indicated clinical nutrition as a primary cost driver. Management of infants presenting with eczema, exclusively formula-fed infants, and first line use of AAF were associated with higher estimates for 2-year direct medical costs.
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Affiliation(s)
- Bulent Enis Sekerel
- a Department of Pediatric Allergy and Asthma , Hacettepe University Faculty of Medicine , Ankara , Turkey
| | - Oznur Seyhun
- b ISPOR Nutrition Economics Special Working Group (NESWG) member of leadership
- c Abbott Laboratories , Istanbul , Turkey
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Amino Acid-based Formula in Cow's Milk Allergy: Long-term Effects on Body Growth and Protein Metabolism. J Pediatr Gastroenterol Nutr 2017; 64:632-638. [PMID: 27437928 DOI: 10.1097/mpg.0000000000001337] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The long-term effects of amino acid-based formula (AAF) in the treatment of cow's milk allergy (CMA) are largely unexplored. The present study comparatively evaluates body growth and protein metabolism in CMA children treated with AAF or with extensively hydrolyzed whey formula (eHWF), and healthy controls. METHODS A 12-month multicenter randomized control trial was conducted in outpatients with CMA (age 5-12 m) randomized in 2 groups, treated with AAF (group 1) and eHWF (group 2), and compared with healthy controls (group 3) fed with follow-on (if age <12 months) or growing-up formula (if age >12 months). At enrolment (T0), after 3 (T3), 6 (T6), and 12 months (T12) a clinical evaluation was performed. At T0 and T3, in subjects with CMA serum levels of albumin, urea, total protein, retinol-binding protein, and insulin-like growth factor 1 were measured. RESULTS Twenty-one subjects in group 1 (61.9% boys, age 6.5 ± 1.5 months), 19 in group 2 (57.9% boys, age 7 ± 1.7 months) and 25 subjects in group 3 (48% boys, age 5.5 ± 0.5 months) completed the study. At T0, the weight z score was similar in group 1 (-0.74) and 2 (-0.76), with differences compared to group 3 (-0.17, P < 0.05). At T12, the weight z score value was similar between the 3 groups without significant differences. There were no significant changes in protein metabolism in children in groups 1 and 2. CONCLUSION Long-term treatment with AAF is safe and allows adequate body growth in children with CMA.
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Morais MBD, Spolidoro JV, Vieira MC, Cardoso AL, Clark O, Nishikawa A, Castro APM. Amino acid formula as a new strategy for diagnosing cow's milk allergy in infants: is it cost-effective? J Med Econ 2016; 19:1207-1214. [PMID: 27441755 DOI: 10.1080/13696998.2016.1211390] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
AIMS To estimate the cost-effectiveness of a new strategy that uses an amino acid formula in the elimination diet of infants with suspected cow's milk allergy (CMA). MATERIALS AND METHODS This pharmacoeconomic study was developed from the perspective of the Brazilian Public Healthcare System. The new strategy proposes using an amino acid formula in the diagnostic elimination diet of infants (≤24 months) with suspected CMA. The rationale is that infants who do not respond to the amino acid formula do not suffer from CMA. Patients with a positive oral challenge test receive a therapeutic elimination diet based on Brazilian Food Allergy Guidelines. This approach was compared to the current recommendations of the Brazilian Food Allergy Guidelines. A decision model was constructed using TreeAge Pro 2012 software. Model inputs were based on a literature review and the opinions of a panel of experts. A univariate sensitivity analysis of incremental cost-effectiveness ratios was performed. RESULTS The mean cost per patient of the new amino acid formula strategy was R$3,341.57, while the cost of the current Brazilian guidelines strategy was R$3,641.08. The mean number of symptom-free days per patient, which was used as an indicator of effectiveness, was 900.6 and 875.7 days, respectively. The new strategy is, therefore, dominant. In the sensitivity analysis, the dominance was maintained with parameter variation. LIMITATIONS In the absence of information in the literature, some premises were defined by a panel of specialists. CONCLUSIONS The new strategy, which uses an amino acid formula in the elimination diagnostic diet followed by an oral food challenge, is a dominant pharmacoeconomic approach that has a lower cost and results in an increased number of symptom-free days.
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Affiliation(s)
| | - José Vicente Spolidoro
- b School of Medicine - Pontifical University of Rio Grande do Sul (PUCRS) , Porto Alegre , Brazil
- c Hospital Moinhos de Vento , Porto Alegre , RS , Brazil
| | - Mário César Vieira
- d School of Medicine - Pontifical University of Paraná (PUCPR) , Curitiba , Brazil
- e Hospital Pequeno Príncipe, Curitiba , Brazil
| | - Ary Lopes Cardoso
- f Instituto da Criança, Hospital das Clínicas, Universidade de São Paulo , São Paulo , Brazil
| | - Otavio Clark
- g Evidencias - a Kantar Health Company, Campinas , Brazil
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Guest JF, Yang AC, Oba J, Rodrigues M, Caetano R, Polster L. Relative cost-effectiveness of using an extensively hydrolyzed casein formula in managing infants with cow's milk allergy in Brazil. CLINICOECONOMICS AND OUTCOMES RESEARCH 2016; 8:629-639. [PMID: 27799804 PMCID: PMC5076537 DOI: 10.2147/ceor.s113448] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Objective To estimate the cost-effectiveness of three alternative dietetic strategies for cow’s milk allergy in Brazil: 1) using an extensively hydrolyzed casein formula (eHCF; Nutramigen) as a first-line formula, but switching to an amino acid formula (AAF) if infants remain symptomatic; 2) using an AAF as a first-line formula and then switching to an eHCF after 4 weeks once infants are symptom-free, but switching back to an AAF if infants become symptomatic; and 3) using an AAF as a first-line formula and keeping all infants on that formula. The analysis was conducted from the perspective of the Brazilian public health care system, Sistema Único de Saude. Methods Decision modeling was used to estimate the probability of immunoglobulin E (IgE)-mediated and non-IgE-mediated allergic infants developing tolerance to cow’s milk by 12 months from starting a formula. The models also estimated the Sistema Único de Saude cost (at 2013/2014 prices) of managing infants over 12 months after starting a formula, as well as the relative cost-effectiveness of each of the dietetic strategies. Results The probability of developing tolerance to cow’s milk by 12 months from starting a formula was higher among infants with either IgE-mediated or non-IgE-mediated allergy who were initially fed with an eHCF, compared with those who were initially fed with an AAF. The total health care cost of initially feeding an eHCF to cow’s milk allergic infants was less than that of initially feeding both IgE-mediated and non-IgE-mediated infants with an AAF. Conclusion Within the study’s limitations, using an eHCF instead of an AAF for the first-line management of newly-diagnosed infants with cow’s milk allergy affords a cost-effective use of publicly funded resources, since it improves the outcome for less cost.
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Affiliation(s)
- Julian F Guest
- Catalyst Health Economics Consultants, Northwood, Middlesex, UK; Faculty of Life Sciences and Medicine, King's College, London, UK
| | - Ariana C Yang
- Universidade de São Paulo, São Paulo & Universidade Estadual de Campinas, São Paulo, Brazil
| | - Jane Oba
- Hospital Israelita Albert Einstein, São Paulo, Brazil & Hospital Municipal Menino Jesus, São Paulo, Brazil
| | - Maraci Rodrigues
- Department of Gastroenterology, University of São Paulo School of Medicine, São Paulo, Brazil
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Guest JF, Weidlich D, Kaczmarski M, Jarocka-Cyrta E, Kobelska-Dubiel N, Krauze A, Sakowska-Maliszewska I, Zawadzka-Krajewska A. Relative cost-effectiveness of using an extensively hydrolyzed casein formula containing the probiotic Lactobacillus rhamnosus GG in managing infants with cow's milk allergy in Poland. CLINICOECONOMICS AND OUTCOMES RESEARCH 2016; 8:307-16. [PMID: 27418845 PMCID: PMC4934487 DOI: 10.2147/ceor.s105748] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective To estimate the cost-effectiveness of using an extensively hydrolyzed casein formula (eHCF) containing the probiotic Lactobacillus rhamnosus GG (eHCF + LGG; Nutramigen LGG) as an initial treatment for cow’s milk allergy compared with eHCF alone and amino acid formulas (AAF) in Poland from the perspective of the Polish National Health Fund (Narodowy Fundusz Zdrowia [NFZ]) and parents. Methods Decision modeling was used to estimate the probability of cow’s milk allergic infants developing tolerance to cow’s milk by 18 months. The model also estimated the cost to the NFZ and parents (Polish Zloty [PLN] at 2013–2014 prices) for managing infants over 18 months after starting one of the formulas as well as the relative cost-effectiveness of each of the formulas. Results The probability of developing tolerance to cow’s milk by 18 months was higher among infants who were fed eHCF + LGG (0.82) compared with those fed eHCF alone (0.53) or an AAF (0.22). An infant who is initially managed with eHCF + LGG is expected to consume fewer health care resources than infants managed with the other formulas. Hence, the estimated total health care cost incurred by the NFZ for initially feeding infants with eHCF + LGG (PLN 5,693) was less than that of feeding infants with eHCF alone (PLN 7,749) or an AAF (PLN 24,333). However, the total cost incurred by parents for initially feeding infants with an AAF (PLN 815) was marginally less than that of feeding with eHCF + LGG (PLN 993), which was less than that of feeding with eHCF alone (PLN 1,226). Conclusion Using eHCF + LGG instead of eHCF alone or an AAF for first-line management of newly diagnosed infants with cow’s milk allergy affords a cost-effective use of NFZ-funded resources, since it improves outcome for less cost. Whether eHCF + LGG would be viewed as being cost-effective by parents is dependent on their willingness to pay an additional cost for additional tolerance acquisition to cow’s milk.
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Affiliation(s)
- Julian F Guest
- Catalyst Health Economics Consultants, Northwood, Middlesex; Faculty of Life Sciences and Medicine, King's College, London, UK
| | - Diana Weidlich
- Catalyst Health Economics Consultants, Northwood, Middlesex
| | - Maciej Kaczmarski
- Department of Pediatrics, Gastroenterology, and Allergology, Medical University of Bialystok, Białystok
| | - Elzbieta Jarocka-Cyrta
- Uniwersytet Warmińsko-Mazurski, Wydział Nauk Medycznych, Katedra Pediatrii Klinicznej, Olsztyn
| | - Natalia Kobelska-Dubiel
- Department of Pediatric Gastroenterology and Metabolic Diseases, Poznań University of Medical Sciences, Poznań
| | | | | | - Anna Zawadzka-Krajewska
- Department of Pediatric Pneumonology and Allergology, Medical University of Warsaw, Warsaw, Poland
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Signs and symptoms associated with digestive tract development. J Pediatr (Rio J) 2016; 92:S46-56. [PMID: 27020622 DOI: 10.1016/j.jped.2016.02.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 02/24/2016] [Accepted: 02/20/2016] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To analyze the development and prevalence of gastrointestinal signs and symptoms associated with the development of the digestive tract, and to assess the measures aimed to reduce their negative impacts. SOURCE OF DATA Considering the scope and comprehensiveness of the subject, a systematic review of the literature was not carried out. The Medline database was used to identify references that would allow the analysis of the study topics. SYNTHESIS OF RESULTS Infants frequently show several gastrointestinal signs and symptoms. These clinical manifestations can be part of gastrointestinal functional disorders such as infantile colic, infant regurgitation, and functional constipation. Allergy to cow's milk protein and gastroesophageal reflux disease are also causes of these clinical manifestations and represent an important and difficult differential diagnosis. The diseases that course with gastrointestinal signs and symptoms can have an impact on family dynamics and maternal emotional status, and may be associated with future problems in the child's life. Comprehensive pediatric care is essential for diagnosis and treatment. Maternal breastfeeding should always be maintained. Some special formulas can contribute to the control of clinical manifestations depending on the established diagnosis. CONCLUSION During the normal development of the digestive tract, several gastrointestinal signs and symptoms may occur, usually resulting from functional gastrointestinal disorders, gastroesophageal reflux disease, and allergy to cow's milk protein. Breastfeeding should always be maintained.
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Abstract
OBJECTIVES Cow's milk allergy (CMA) is the most common food allergy in children with many clinical manifestations, leading to misdiagnoses such as gastro-oesophageal reflux, infantile colic, and lactose intolerance with inappropriate prescribing. We aimed to determine the impact of infant feeding guidelines on CMA prescribing in UK primary care using a simple and inexpensive training package. METHODS Prospectively collected data of infant feeding prescriptions in Northern Ireland from June 2012 to March 2014 were analysed with the intervention period between November 2012 and March 2013. A comparison was made between hypoallergenic formulae, appropriate for CMA, versus alternative prescriptions including antiregurgitation and colic products, lactose-free and partially hydrolysed milks, or infant Gaviscon. RESULTS Comparing pre- and postintervention period, the total quantity of hypoallergenic formulae increased by 63.2% and alternative prescriptions decreased by 44.6% (P < 0.001). The total amount of all prescribed products decreased by 41.0% (P < 0.001). During the study period, the proportion of recommended CMA treatment increased from 3.4% before training to 9.8% in the short- and long-term follow-up (P < 0.001). The overall increase was £33,508 per year or £95.5 per general practitioner's surgery. CONCLUSIONS We present the first study evaluating the impact of infant feeding guidelines on CMA prescribing in UK primary care. Practical advice and teaching of health professionals allowed for effective implementation of regional and national guidelines, with a significant impact on prescription patterns. This study shows promising results for prospective research on a national scale, including socioeconomical impact and cost-effectiveness.
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de Morais MB. Signs and symptoms associated with digestive tract development. JORNAL DE PEDIATRIA (VERSÃO EM PORTUGUÊS) 2016. [DOI: 10.1016/j.jpedp.2016.03.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Abstract
Partially hydrolyzed formulas (pHFs) are increasingly used worldwide, both in the prevention of atopic disease in at-risk infants and in the therapeutic management of infants with functional gastrointestinal manifestations. Because prevention is always preferable to treatment, we reviewed the literature aiming to find an answer for the question whether pHF may be recommended for feeding all infants if breast-feeding is not possible. PubMed and Cochrane databases were searched up to December 2014. In addition, to search for data that remained undetected by the searches, we approached authors of relevant articles and major producers of pHFs asking for unpublished data. Because few data were found, nonrandomized, controlled trials and trials in preterm infants were included as well. Overall, only limited data could be found on the efficacy and safety of pHF in healthy term infants. Available data do not indicate that pHFs are potentially harmful for healthy, term infants. With respect to long-term outcomes, particularly referring to immune, metabolic and hormonal effects, data are, however, nonexistent. From a regulatory point of view, pHFs meet the nutrient requirements to be considered as standard formula for term healthy infants. Cost, which is different from country to country, should be considered in the decision-making process. Based on limited available data, the use of pHF in healthy infants is safe with regard to growth. The lack of data, in particular for metabolic consequences and long-term outcomes, is, however, the basis for our recommendation that health authorities should develop and support long-term follow-up studies. Efficacy and long-term safety data are required before a recommendation of this type of formula for all infants can be made.
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Guest JF, Weidlich D, Mascuñan Díaz JI, Díaz JJ, Ojeda PM, Ferrer-González JP, Gil D, Onrubia I, Rincón Victor P. Relative cost-effectiveness of using an extensively hydrolyzed casein formula containing the probiotic Lactobacillus rhamnosus GG in managing infants with cow's milk allergy in Spain. CLINICOECONOMICS AND OUTCOMES RESEARCH 2015; 7:583-91. [PMID: 26648744 PMCID: PMC4664436 DOI: 10.2147/ceor.s89347] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To estimate the cost-effectiveness of using an extensively hydrolyzed casein formula containing the probiotic Lactobacillus rhamnosus GG (eHCF + LGG; Nutramigen LGG) as a first-line management for cow's milk allergy compared with eHCF alone, and amino acid formulae in Spain, from the perspective of the Spanish National Health Service (SNS). METHODS Decision modeling was used to estimate the probability of immunoglobulin E (IgE)-mediated and non-IgE-mediated allergic infants developing tolerance to cow's milk by 18 months. The models also estimated the SNS cost (at 2012/2013 prices) of managing infants over 18 months after starting a formula as well as the relative cost-effectiveness of each of the formulae. RESULTS The probability of developing tolerance to cow's milk by 18 months was higher among infants with either IgE-mediated or non-IgE-mediated allergy who were fed eHCF + LGG compared with those fed one of the other formulae. The total health care cost of initially feeding infants with eHCF + LGG was less than that of feeding infants with one of the other formulae. Hence, eHCF + LGG affords the greatest value for money to the SNS for managing both IgE-mediated and non-IgE-mediated cow's milk allergy. CONCLUSION Using eHCF + LGG instead of eHCF alone or amino acid formulae for first-line management of newly-diagnosed infants with cow's milk allergy affords a cost-effective use of publicly funded resources because it improves outcome for less cost. A randomized controlled study showing faster tolerance development in children receiving a probiotic-containing formula is required before this conclusion can be confirmed.
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Affiliation(s)
- Julian F Guest
- Catalyst Health Economics Consultants, Northwood, Middlesex, UK
- Faculty of Life Sciences and Medicine, King’s College, London, UK
| | - Diana Weidlich
- Catalyst Health Economics Consultants, Northwood, Middlesex, UK
| | | | - Juan J Díaz
- Hospital Universitario Central de Asturias, Oviedo, Spain
| | | | | | - David Gil
- Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
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Guest JF, Panca M, Ovcinnikova O, Nocerino R. Relative cost-effectiveness of an extensively hydrolyzed casein formula containing the probiotic Lactobacillus rhamnosus GG in managing infants with cow's milk allergy in Italy. CLINICOECONOMICS AND OUTCOMES RESEARCH 2015; 7:325-36. [PMID: 26089692 PMCID: PMC4467649 DOI: 10.2147/ceor.s80130] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To estimate the cost-effectiveness of using an extensively hydrolyzed casein formula (eHCF) containing the probiotic Lactobacillus rhamnosus GG, (eHCF + LGG; Nutramigen LGG) as first-line management for cow's milk allergy (CMA) compared with eHCF alone, soy-based formulae (SBF), hydrolyzed rice formulae (HRF), and amino acid formulae (AAF) in Italy, from the perspective of the Italian National Health Service (INHS) and parents. METHODS Decision modeling was used to estimate the probability of infants developing tolerance to cow's milk by 18 months, based on an observational study dataset. The model also estimated the cost (at 2012/2013 prices) of health care resource use funded by the INHS and formulae paid for by parents over 18 months after starting a formula, as well as the relative cost-effectiveness of each of the formulae. RESULTS The probability of developing tolerance to cow's milk by 18 months was higher among infants with either IgE-mediated or non-IgE-mediated allergy who were fed eHCF + LGG compared to those fed one of the other formulae. The total health care cost of initially feeding infants with eHCF + LGG was less than that of feeding infants with one of the other formulae. Hence, eHCF + LGG affords the greatest value for money to both the INHS and parents of infants with either IgE-mediated or non-IgE-mediated CMA. CONCLUSION Using eHCF + LGG instead of eHCF, SBF, HRF, or an AAF for first-line management of newly diagnosed infants with CMA in Italy affords a cost-effective use of publicly funded resources, and is cost-effective from the parents' perspective, since it improves outcome for less cost. A randomized controlled study showing faster tolerance development in children receiving a probiotic-containing formula is required before this conclusion can be confirmed.
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Affiliation(s)
- Julian F Guest
- CATALYST Health Economics Consultants, Northwood, Middlesex, UK
- Faculty of Life Sciences and Medicine, King’s College, London, UK
| | - Monica Panca
- CATALYST Health Economics Consultants, Northwood, Middlesex, UK
| | | | - Rita Nocerino
- Department of Translational Medical Science, Pediatric Section, University of Naples ‘Federico II’, Naples, Italy
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Bhanegaonkar A, Horodniceanu EG, Ji X, Detzel P, Boguniewicz M, Chamlin S, Lake A, Czerkies LA, Botteman MF, Saavedra JM. Economic Burden of Atopic Dermatitis in High-Risk Infants Receiving Cow's Milk or Partially Hydrolyzed 100% Whey-Based Formula. J Pediatr 2015; 166:1145-1151.e3. [PMID: 25919724 DOI: 10.1016/j.jpeds.2015.02.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Revised: 01/23/2015] [Accepted: 02/06/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To estimate the health and economic impact of feeding partially hydrolyzed formula-whey (PHF-W) instead of standard cow's milk formula (CMF) for the first 4 months of life among US infants at high risk for developing atopic dermatitis (AD). STUDY DESIGN A Markov model was developed integrating published data, a survey of US pediatricians, costing sources and market data, and expert opinion. Key modeled outcomes included reduction in AD risk, time spent post AD diagnosis, days without AD flare, and AD-related costs. Costs and clinical consequences were discounted at 3% annually. RESULTS An estimated absolute 14-percentage point reduction in AD risk was calculated with the use of PHF-W compared with CMF (95% CI for difference, 3%-22%). Relative to CMF, PHF-W decreased the time spent post-AD diagnosis by 8.3 months (95% CI, 2.78-13.31) per child and increased days without AD flare by 39 days (95% CI, 13-63) per child. The AD-related, 6-year total cost estimate was $495 less (95% CI, -$813 to -$157) per child with PHF-W ($724 per child; 95% CI, $385-$1269) compared with CMF ($1219 per child; 95% CI, $741-$1824). CONCLUSION Utilization of PHF-W in place of CMF as the initial infant formula administered to high-risk US infants not exclusively breastfed during the first 4 months of life may reduce the incidence and economic burden of AD. Broad implementation of this strategy could result in a minimum savings of $355 million per year to society.
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Affiliation(s)
| | | | - Xiang Ji
- Pharmerit International, Bethesda, MD
| | | | - Mark Boguniewicz
- Department of Pediatrics, National Jewish Health and University of Colorado School of Medicine, Denver, CO
| | - Sarah Chamlin
- Division of Pediatric Dermatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Alan Lake
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - José M Saavedra
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD; Nestlé Nutrition, Florham Park, NJ
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Ovcinnikova O, Panca M, Guest JF. Cost-effectiveness of using an extensively hydrolyzed casein formula plus the probiotic Lactobacillus rhamnosus GG compared to an extensively hydrolyzed formula alone or an amino acid formula as first-line dietary management for cow's milk allergy in the US. CLINICOECONOMICS AND OUTCOMES RESEARCH 2015; 7:145-52. [PMID: 25767400 PMCID: PMC4354430 DOI: 10.2147/ceor.s75071] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES The aim was to estimate the cost-effectiveness of using an extensively hydrolyzed casein formula (eHCF) plus the probiotic Lactobacillus rhamnosus GG (eHCF + LGG; Nutramigen LGG) compared to an eHCF alone (Nutramigen) and an amino acid formula (AAF; Neocate) as first-line dietary management for cow's milk allergy (CMA) in the US. METHODS Using a cohort study design, the analysis was based on the case records of 136 eHCF-fed, 59 eHCF + LGG-fed, and 217 matched AAF-fed infants extracted from the Truven Health MarketScan(®) Commercial Claims Database (a nationally representative database of the commercially insured population of the US). Clinical outcomes and health care resource use (with corresponding costs at 2012 prices), following first-line dietary management with each formula, were estimated over 12 months from the start of feeding. Differences in infants' outcomes and resource use between groups were adjusted for any differences in baseline covariates. RESULTS Infants were <6 months of age at presentation. Fifty-six percent of eHCF + LGG-fed infants were estimated to have been successfully managed by 9 months compared to 38% of eHCF-fed infants and 35% of AAF-fed infants (P<0.05 and P=0.003 respectively). Infants in the AAF group used significantly more health care resources and prescribed drugs than infants in the other two groups. The estimated cost of managing a CMA infant over the first 12 months following the start of feeding was $3,577, $3,781, and $6,255 for an eHCF + LGG-fed, eHCF-fed, and AAF-fed infant, respectively. Parents' costs accounted for up to 10% of the total costs and the remainder was incurred by insurers. The analyses were robust to plausible changes in all variables. CONCLUSION Using real world evidence, initial dietary management with eHCF + LGG appears to afford a more cost-effective use of health care resources than initial dietary management with eHCF or AAF since it releases health care resources for alternative use within the system and reduces costs without impacting on the time needed to manage the allergy.
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Affiliation(s)
| | - Monica Panca
- CATALYST Health Economics Consultants, Northwood, London, UK
| | - Julian F Guest
- CATALYST Health Economics Consultants, Northwood, London, UK ; Faculty of Life Sciences and Medicine, King's College, London, UK
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Cipriani F, Dondi A, Ricci G. Recent advances in epidemiology and prevention of atopic eczema. Pediatr Allergy Immunol 2014; 25:630-8. [PMID: 25406640 DOI: 10.1111/pai.12309] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/14/2014] [Indexed: 12/22/2022]
Abstract
Atopic dermatitis (AD), named also atopic eczema, is a chronic relapsing inflammatory skin disease with a considerable social and economic burden. The primum movens of AD is in most cases a genetic and/or immune-supported defect of the skin barrier, facilitating penetration and sensitization to food or airborne allergens, as well as infections by Staphylococcus aureus, herpes simplex virus, or other microbes. New pathogenetic concepts have generated new approaches to prevention and therapy of AD. In particular, the daily use of emollients in newborns at high risk of AD has shown interesting results, with a reduction in the cumulative incidence of AD ranging from 32% to 50% of the treated infants. On the other hand, the AD preventive efficacy of food and/or inhalant allergen avoidance has been questioned, and supplementation strategies (vitamin D, probiotics, or other compounds) need to be further investigated.
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Affiliation(s)
- Francesca Cipriani
- Pediatric Unit, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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Vandenplas Y, Abuabat A, Al-Hammadi S, Aly GS, Miqdady MS, Shaaban SY, Torbey PH. Middle East Consensus Statement on the Prevention, Diagnosis, and Management of Cow's Milk Protein Allergy. Pediatr Gastroenterol Hepatol Nutr 2014; 17:61-73. [PMID: 25061580 PMCID: PMC4107222 DOI: 10.5223/pghn.2014.17.2.61] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 04/01/2014] [Indexed: 11/23/2022] Open
Abstract
Presented are guidelines for the prevention, diagnosis, and treatment of cow's milk protein allergy (CMPA) which is the most common food allergy in infants. It manifests through a variety of symptoms that place a burden on both the infant and their caregivers. The guidelines were formulated by evaluation of existing evidence-based guidelines, literature evidence and expert clinical experience. The guidelines set out practical recommendations and include algorithms for the prevention and treatment of CMPA. For infants at risk of allergy, appropriate prevention diets are suggested. Breastfeeding is the best method for prevention; however, a partially hydrolyzed formula should be used in infants unable to be breastfed. In infants with suspected CMPA, guidelines are presented for the appropriate diagnostic workup and subsequent appropriate elimination diet for treatment. Exclusive breastfeeding and maternal dietary allergen avoidance are the best treatment. In infants not exclusively breastfed, an extensively hydrolyzed formula should be used with amino acid formula recommended if the symptoms are life-threatening or do not resolve after extensively hydrolyzed formula. Adherence to these guidelines should assist healthcare practitioners in optimizing their approach to the management of CMPA and decrease the burden on infants and their caregivers.
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Affiliation(s)
- Yvan Vandenplas
- Department of Pediatrics, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Ahmed Abuabat
- King Abdullah Bin Abdul Aziz University Hospital, Princess Nora Bint Abdulrahman University, Riyadh, Kingdom of Saudi Arabia
| | - Suleiman Al-Hammadi
- Department of Pediatrics, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain, United Arab Emirates
| | - Gamal Samy Aly
- Department of Child Health and Nutrition, Institute of Postgraduate Childhood Studies, Ain Shams University, Cairo, Egypt
| | - Mohamad S Miqdady
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | | | - Paul-Henri Torbey
- Department of Pediatrics, Hôtel-Dieu de France, St. Joseph University, Beirut, Lebanon
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Walzer S, Droeschel D, Nuijten M, Chevrou-Séverac H. Health economics evidence for medical nutrition: are these interventions value for money in integrated care? CLINICOECONOMICS AND OUTCOMES RESEARCH 2014; 6:241-52. [PMID: 24876787 PMCID: PMC4035106 DOI: 10.2147/ceor.s58852] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Health care decision-makers have begun to realize that medical nutrition plays an important role in the delivery of care, and it needs to be seen as a sole category within the overall health care reimbursement system to establish the value for money. Indeed, improving health through improving patients' nutrition may contribute to the cost-effectiveness and financial sustainability of health care systems. Medical nutrition is regulated by a specific bill either in Europe or in the United States, which offers specific legislations and guidelines (as provided to patients with special nutritional needs) and indications for nutritional support. Given that the efficacy of medical nutrition has been proven, one can wonder whether the heterogeneous nature of its coverage/reimbursement across countries might be due to the lack of health-related economic evidence or value-for-money of nutritional interventions. This paper aims to address this knowledge gap by performing a systematic literature review on health economics evidence regarding medical nutrition, and by summarizing the results of these publications related to the value for money of medical nutrition interventions. METHODS A systematic literature search was initiated and executed based on a predefined search protocol following the population, intervention, comparison, and outcomes (PICO) criteria. Following the systematic literature search of recently published literature on health economics evidence regarding medical nutrition, this study aims to summarize the results of those publications that are related to the value for money of medical nutrition interventions. The evaluations were conducted by analyzing different medical nutrition according to their indications, the economic methodology or perspective adopted, the cost source and utility measures, selected efficiency measures, as well as the incremental cost-effectiveness ratio. RESULTS A total of 225 abstracts were identified for the detailed review, and the data were entered into a data extraction sheet. For the abstracts that finally met the predefined inclusion criteria (n=53), full-text publications were obtained via PubMed, subito, or directly via each journal's Webpage for further assessment. After a detailed review of the full text articles, 34 publications have been qualified for a thorough data extraction procedure. When differentiating the resulting articles in terms of their settings, 20 studies covered inpatients, whereas 14 articles covered outpatients, including patients in community centers. When reviewing the value-for-money evaluations, the indications showed that the different results were mostly impacted by the different perspectives adopted and the comparisons that were made. In order to draw comprehensive conclusions, the results were split according to the main indications and diseases. DISCUSSION The systematic literature search has shown that there is not only an interest in health economics and its application in medical nutrition, but that there is a lot of ongoing research in this area. Based on the underlying systematic analysis, it has been shown that medical nutrition interventions offer value for money in the different health care settings, particularly for the specific disease areas that have been pointed out. CONCLUSION Based on the systematic literature search that was performed, it was shown that medical nutrition interventions offer value for money in the different health care settings. Although medical nutrition has been the topic of some health economic analyses, the usual willingness to pay threshold used in health care rarely was applied. Often, these products are either directly part of a lump sum in the financing system (for example, diagnosis-related groups), or they are covered as out-of-pocket payments by patients directly. More research would be necessary to better understand how medical nutrition interventions can be optimally funded by the health care system, given the clinical value they bring to patients in their recovery process.
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Affiliation(s)
- Stefan Walzer
- MArS Market Access and Pricing Strategy GmbH, Weil am Rhein, Germany
- State University Baden Wuerttemberg, Loerach, Germany
| | - Daniel Droeschel
- MArS Market Access and Pricing Strategy GmbH, Weil am Rhein, Germany
- Riedlingen University, SRH FernHochschule, Riedlingen, Germany
| | - Mark Nuijten
- Ars Accessus Medica BV, Jisp, Amsterdam, the Netherlands
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Walzer S, Droeschel D, Nuijten M, Chevrou-Séverac H. Health economic analyses in medical nutrition: a systematic literature review. CLINICOECONOMICS AND OUTCOMES RESEARCH 2014; 6:109-24. [PMID: 24648747 PMCID: PMC3956482 DOI: 10.2147/ceor.s53601] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background Medical nutrition is a specific nutrition category either covering specific dietary needs and/or nutrient deficiency in patients or feeding patients unable to eat normally. Medical nutrition is regulated by a specific bill in Europe and in the US, with specific legislation and guidelines, and is provided to patients with special nutritional needs and indications for nutrition support. Therefore, medical nutrition products are delivered by medical prescription and supervised by health care professionals. Although these products have existed for more than 2 decades, health economic evidence of medical nutrition interventions is scarce. This research assesses the current published health economic evidence for medical nutrition by performing a systematic literature review related to health economic analysis of medical nutrition. Methods A systematic literature search was done using standard literature databases, including PubMed, the Health Technology Assessment Database, and the National Health Service Economic Evaluation Database. Additionally, a free web-based search was conducted using the same search terms utilized in the systematic database search. The clinical background and basis of the analysis, health economic design, and results were extracted from the papers finally selected. The Drummond checklist was used to validate the quality of health economic modeling studies and the AMSTAR (A Measurement Tool to Assess Systematic Reviews) checklist was used for published systematic reviews. Results Fifty-three papers were identified and obtained via PubMed, or directly via journal webpages for further assessment. Thirty-two papers were finally included in a thorough data extraction procedure, including those identified by a “gray literature search” utilizing the Google search engine and cross-reference searches. Results regarding content of the studies showed that malnutrition was the underlying clinical condition in most cases (32%). In addition, gastrointestinal disorders (eg, surgery, cancer) were often analyzed. In terms of settings, 56% of papers covered inpatients, whereas 14 papers (44%) captured outpatients, including patients in community centers. Interestingly, in comparison with the papers identified overall, very few health economic models were found. Most of the articles were modeling analyses and economic trials in different design settings. Overall, only eight health economic models were published and were validated applying the Drummond checklist. In summary, most of the models included were carried out to quite a high standard, although some areas were identified for further improvement. Of the two systematic health economic reviews identified, one achieved the highest quality score when applying the AMSTAR checklist. Conclusion The reasons for finding only a few modeling studies but quite a large number of clinical trials with health economic endpoints, might be different. Until recently, health economics has not been required for reimbursement or coverage decisions concerning medical nutrition interventions. Further, there might be specifics of medical nutrition which might not allow easy modeling and consequently explain the limited uptake so far. The health economic data on medical nutrition generated and published is quite ample. However, it has been primarily based on database analysis and clinical studies. Only a few modeling analyses have been carried out, indicating a need for further research to understand the specifics of medical nutrition and their applicability for health economic modeling.
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Affiliation(s)
- Stefan Walzer
- MArS Market Access and Pricing Strategy GmbH, Weil am Rhein, Germany ; State University Baden-Wuerttemberg, Loerrach, Germany
| | - Daniel Droeschel
- MArS Market Access and Pricing Strategy GmbH, Weil am Rhein, Germany ; Riedlingen University, SRH FernHochschule, Riedlingen, Germany
| | - Mark Nuijten
- Ars Accessus Medica BV, Amsterdam, the Netherlands
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Borschel MW, Ziegler EE, Wedig RT, Oliver JS. Growth of healthy term infants fed an extensively hydrolyzed casein-based or free amino acid-based infant formula: a randomized, double-blind, controlled trial. Clin Pediatr (Phila) 2013; 52:910-7. [PMID: 23820000 DOI: 10.1177/0009922813492883] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A masked, randomized, parallel growth study was conducted in infants fed an amino acid-based formula (AF) or an extensively hydrolyzed casein-based formula (HF). Infants were enrolled between 0 and 9 days and studied to 112 days of age. Growth, formula intake, stool patterns, and serum albumin concentrations were assessed. There were no significant differences between groups in weight, length, or head circumference, gains in weight or length, or study formula intake. The number of stools parents rated as being formed, and the mean daily number of stools were greater in the HF than in the AF group at 14 and 28 days of age. Mean serum albumin concentrations were not significantly different between groups and were within the normal range. This study demonstrates that AF supports normal growth of infants comparable to that of infants fed HF during the critical first 4 months of life.
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Hochwallner H, Schulmeister U, Swoboda I, Spitzauer S, Valenta R. Cow's milk allergy: from allergens to new forms of diagnosis, therapy and prevention. Methods 2013; 66:22-33. [PMID: 23954566 PMCID: PMC3969108 DOI: 10.1016/j.ymeth.2013.08.005] [Citation(s) in RCA: 141] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2013] [Revised: 07/31/2013] [Accepted: 08/03/2013] [Indexed: 12/22/2022] Open
Abstract
The first adverse reactions to cow's milk were already described 2,000 years ago. However, it was only 50 years ago that several groups started with the analysis of cow's milk allergens. Meanwhile the spectrum of allergy eliciting proteins within cow's milk is identified and several cow's milk allergens have been characterized regarding their biochemical properties, fold and IgE binding epitopes. The diagnosis of cow's milk allergy is diverse ranging from fast and cheap in vitro assays to elaborate in vivo assays. Considerable effort was spent to improve the diagnosis from an extract-based into a component resolved concept. There is still no suitable therapy available against cow's milk allergy except avoidance. Therefore research needs to focus on the development of suitable and safe immunotherapies that do not elicit severe side effect.
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Affiliation(s)
- Heidrun Hochwallner
- Division of Immunopathology, Department of Pathophysiology and Allergy Research, Medical University of Vienna, Austria.
| | - Ulrike Schulmeister
- Department of Medical and Chemical Laboratory Diagnostics, Medical University of Vienna, Austria
| | - Ines Swoboda
- Division of Immunopathology, Department of Pathophysiology and Allergy Research, Medical University of Vienna, Austria
| | - Susanne Spitzauer
- Department of Medical and Chemical Laboratory Diagnostics, Medical University of Vienna, Austria
| | - Rudolf Valenta
- Division of Immunopathology, Department of Pathophysiology and Allergy Research, Medical University of Vienna, Austria
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Lucendo AJ, Arias Á, González-Cervera J, Mota-Huertas T, Yagüe-Compadre JL. Tolerance of a cow's milk-based hydrolyzed formula in patients with eosinophilic esophagitis triggered by milk. Allergy 2013; 68:1065-72. [PMID: 23906026 DOI: 10.1111/all.12200] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND Cow's milk protein, a major food trigger for EoE in both children and adults, should be continuously avoided once identified as such. This study evaluates tolerance of a cow's milk-based extensively hydrolyzed formula (eHF) with regard to disease remission maintenance in adult patients with milk-triggered EoE. METHODS Seventeen adult patients in whom cow's milk was consecutively demonstrated to trigger EoE after an empiric six-food elimination diet-based study protocol and who subsequently maintained disease remission were prospectively recruited. They were given 400 ml of a cow's milk-based eHF daily for 8 weeks. Intraepithelial peak eosinophil and blood eosinophil counts, esophageal-related symptoms, serum total and specific IgE to major milk proteins, and eosinophil cationic protein were monitored before and after eHF intake. RESULTS Thirteen male and four female patients aged 17-56 completed the study protocol. 15 patients (88.24%) achieved and maintained EoE remission, while an infiltration of ≥15 eosinophils/hpf reappeared in the remaining two patients. No differences in age, gender, symptoms, and endoscopic appearance at baseline conditions or personal/family allergic background were observed between those patients who tolerated the eHF and those who did not. Symptom scores did not significantly change after eHF intake and were significantly lower than those documented at baseline conditions or after cow's milk challenge. No differences were documented in blood eosinophil counts or serum markers after eHF intake. CONCLUSION Most adult patients with EoE triggered by cow's milk tolerate a cow's milk-based eHF, thus providing them with a safe, economical alternative to cow's milk.
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Affiliation(s)
- A. J. Lucendo
- Department of Gastroenterology; Hospital General de Tomelloso; Ciudad Real; Spain
| | - Á. Arias
- Research Support Unit; Complejo Hospitalario La Mancha Centro; Ciudad Real; Spain
| | | | - T. Mota-Huertas
- Department of Pathology; Complejo Hospitalario La Mancha Centro; Ciudad Real; Spain
| | - J. L. Yagüe-Compadre
- Department of Pathology; Complejo Hospitalario La Mancha Centro; Ciudad Real; Spain
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Abstract
This review highlights the progress made in food allergy (FA) and anaphylaxis research in pediatrics published in the journal Pediatric Allergy and Immunology since 2010. Putative risk factors for FA are as follows: a family history of allergic disease, particularly in the mother, low birth order, season of birth, and severe atopic eczema. Obstetric practices, antibiotic use, and home environment are factors deserving further research. Diagnostic decision levels and component-specific IgE are useful in the diagnosis of FA; however, oral food challenges remain the gold standard and may also be a means to reduce parental anxiety and to improve education. Oral immunotherapy studies show promise in increasing the threshold of reactivity of allergic patients and therefore improving their quality of life. In single-nut-allergic patients, introduction of other nuts allows broadening the diet and thus reducing the psychological impact of allergen avoidance. Nutritional deficiencies are not uncommon in food-allergic children and should be specifically assessed. The prescription of injectable adrenaline is still insufficient and not consistent among practitioners, requiring improved training and implementation of guidelines. Current research into the epidemiology and immunological mechanisms of FA and tolerance will enable us to devise strategies to both prevent and treat food allergies.
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Affiliation(s)
- Alexandra F Santos
- Department of Pediatric Allergy, Division of Asthma, Allergy & Lung Biology, King's College London, MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, London, UK.
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Petrus NCM, Hulshof L, Rutjes NWP, de Vreede I, van Aalderen WMC, Sprikkelman AB. Response to: Cost-effectiveness of using an extensively hydrolysed formula compared to an amino acid formula as first-line treatment for cow milk allergy in the UK. Pediatr Allergy Immunol 2012; 23:686; author reply 687. [PMID: 22985421 DOI: 10.1111/j.1399-3038.2012.01311.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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